It was made known this week that a police inspector will face misconduct proceedings over their initial handling of a missing person’s investigation in 2020 where a detained patient absconded from a private mental health unit in Birmingham.
Matthew Caseby had been admitted to the Priory Hospital in Edgbaston after being sectioned in Oxford. The police in Thames Valley had detained him after he was seen on a railway line and members of the public rang in with concerns for his behaviour. He was located in a nearby playground and detained under section 136 of the Mental Health Act. Having been admitted to the Birmingham unit after assessment, he spent five days on the ward until – on the 7th September – he absconded by climbing over a fence which, on reliable authority, I’m told has been used for patients to escape on other occasions. He was reporting missing to West Midlands Police who conducted a search of the area prior to attending the hospital to secure as many details as they could and it was decided he should be treated as MEDIUM risk. A missing person’s record was opened around 7:20pm that day.
Matthew’s father contacted the police just after 7:30pm and told officers he had concerns Matthew would harm himself. The police had further telephone discussion with Matthew’s mother and sister over the evening and searches were undertaken of the Selly Oak area of the city, including a previous address and place of employment. Throughout this, he remained categorised as MEDIUM risk. Overnight, a further review was undertaken of risk and Matthew remained classified as MEDIUM with no further actions being completed during that shift – the case was listed to be handed to the missing person’s team the next morning.
Incidentally, in case some are wondering why someone originally from London was admitted to a Birmingham mental health unit: Matthew was a University of Birmingham student and had registered with a GP in the city. When we are “sectioned”, the NHS tries to admit you to your “home” area and that is determined by where your GP is and this is why certain specific searches and enquiries in Selly Oak were relevant.
PREVENTING FUTURE DEATHS
Where someone goes missing, the initial call handler makes an inevitably superficial assessment of potential risks based on the bare description of the event and limited questions to help influence how swift a response is required. If it were potentially high-risk from the start, the duty inspector for the area would be informed immediately. If not, the officers allocated would make their initial searches and inquiries to better influence an assessment of the risks involved and once the initial investigation is done, they would liaise with the duty inspector who determines that risk assessment. We don’t (yet) know how those processes and considerations unfolded during the initial late shift where Matthew absconded and therefore, we do not know whether the inspector facing a misconduct meeting is the late shift inspector who oversaw what happened or the night shift inspector who reviewed the matter around 1:27am and decided nothing further was required until the morning.
A Preventing Future Deaths report was issued by the Birmingham Coroner after the inquest in 2022. It is detailed and if you are interested in knowing more than I have covered above, worth reading. The conclusion reached was that Matthew’s death was due to neglect by the Priory Hospital and therefore the first I noted from the PFD was the fact it was not directed at the Chief Constable of West Midlands Police, only at the Priory Hospital and the Department of Health and Social Care. This is where I first became curious about the case – police misconduct for something not flagged as an issue in the PFD notice. The Coroner obviously had every right to investigate whatever they thought necessary, including the police response to the report and to reach whatever findings they thought proper. The adverse finding here, of neglect, was levied at the hospital only and none of the five “matters of concern” in the PFD were aimed at the police, whether operationally or in terms of background policy, procedure or training.
The Independent Office for Police Conduct received a complaint from Matthew’s father, Richard Caseby about the police search and it is that complaint investigation, finalised in December 2024 which leads to the news article today, that an inspector will face a misconduct meeting. Mr Caseby has since stated, “West Midlands Police utterly failed my family when we needed them most” after the IOPC concluded, “We decided that a police inspector should attend a misconduct meeting in relation to their decision making and handling of information after Matthew was reported missing”. This very much makes it sound like the initial, late-shift inspector and a clue as to the view they’ve taken this view is within the PFD notice, linked above.
RISK ASSESSMENT
The process of LOW – MEDIUM – HIGH risk assessment is a discussion of the ages and police forces have always wrestled with these issues, especially for mental health patients. It becomes even more complicated still when you factor in joint-agency responses or decisions because the NHS and in this case private healthcare providers do not always categorise risk in the same way. In my time, I’ve known the NHS insist patients are HIGH risk when I’d die in a ditch to suggest they are MEDIUM and I once knew a consultant psychiatric who told me “all missing mental health patients are high-risk”, something we know is not true. But in Matthew’s case, we know from the PFD that once the missing person’s team reviewed the investigation at 7:00am, they immediately revised the risk assessment upwards from MEDIUM to HIGH. Tragically, in less than two hours Matthew had walked in front of a train just off the Vale campus at the University of Birmingham, less than a mile away from the Priory Hospital.
As I read the PFD thinking about risk, I noted a few things which made me wonder about that initial risk assessment:
The first point was, it was known and knowable to the police from paperwork they were given, Matthew had been found near a railway line and detained under s136 MHA. We also know of Richard Caseby’s phone call to the police around 7:30pm which told officers about his concerns Matthew would harm himself – we obviously know from history, you dismiss family concerns about risk at your peril. The two things taken together mean it could be thought there was an “immediate risk to life” and therefore, a HIGH risk missing person. We can’t know this for certain from these two articles (the BBC news coverage and the PFD) whether that was what the IOPC think or whether it would have made any difference to the outcome.
JOINT PROTOCOLS
The final thing I was left thinking after reading about this sad case was something left entirely unmentioned: the absence of joint protocols and procedures for AWOL patients under the Mental Health Act 1983 – every area of England and Wales should have a selection of joint protocols in place for responses to AWOL patients, and several other Mental Health Act issues. During my final five years of service in WMP, there were no such protocols in existence, except for one on the unrelated topic of how Mental Health Act assessments should be coordinated where conducted in private premises.
I asked about this specifically and flagged it all more than once, incidents I had been obliged to oversee as a duty inspector which were affected by a lack of jointly agreed procedures with healthcare providers and Coroners in Birmingham had, more than once, lamented the absence of such policies or their poor quality and limited dissemination to those who needed to know about them. It was my experience far too many frontline staff were not aware of how to work jointly with other agencies to ensure effective responses mainly because their bosses hadn’t been in rooms together thrashing it all out to ensue there were no gaps or overlaps.
Normally, such protocols are agreed between the police and the National Health Service and the local authority (who run or licence the Approved Mental Health Professionals for the area) and perhaps, the ambulance service. I’ve never known any area make sure their private mental health providers are included and signed up to these things but there’s absolutely no reason why they shouldn’t be and in making criticism of senior managers, I levy this charge equally at all the agencies involved in these partnerships, not just at the police. Too many frontline staff are attempting to get stuff done, without proper agreements in place and training to match it – it’s been like this for decades now and you might imagine after all the inquests, of which Matthew’s is sadly just one, we’d have learned the lessons organisations always promise to learn.
None of this is new, in the end … sadly, it’s all too common.
UPDATE (24/07/25) – a misconduct meeting was held on 23/07/25 and a police inspector has received a written warning for failing to take information in to account and / or dismissing information considered relevant.
Awarded the President’s Medal, by the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2025
I am not a police officer.
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
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